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Additional bypass graft or concomitant surgical ablation? Insights from the HEIST registry
Piotr Suwalski1, Emil Julian Dąbrowski2, Jakub Batko3
1Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland. Electronic address: https://twitter.com/CentreThoracic.
Insights
Surgical ablation for atrial fibrillation during coronary artery bypass grafting offers long-term survival benefits, even with incomplete revascularization. This procedure provides similar outcomes to complete revascularization without ablation.
Area of Science:
- Cardiovascular Surgery
- Electrophysiology
- Cardiac Arrhythmia Management
Background:
- Surgical ablation for atrial fibrillation during coronary artery bypass grafting (CABG) is cautiously performed.
- Achieving complete revascularization in patients with multivessel disease undergoing CABG can be challenging.
- This study evaluates the trade-offs between surgical ablation benefits and incomplete revascularization risks.
Purpose of the Study:
- To assess the long-term survival outcomes of concomitant surgical ablation in patients undergoing CABG for atrial fibrillation.
- To compare outcomes between complete and incomplete revascularization strategies, with and without surgical ablation.
- To determine if surgical ablation offers survival benefits in the context of incomplete revascularization.
Main Methods:
- Retrospective analysis of 8,405 patients from the HEart surgery In atrial fibrillation and Supraventricular Tachycardia registry (2012-2022).
- Patients undergoing isolated CABG for multivessel disease were stratified into complete revascularization, complete with additional grafts, and incomplete revascularization cohorts.
- These cohorts were further divided into surgical ablation and non-surgical ablation subgroups for comparative analysis.
Main Results:
- Surgical ablation was performed in 6.6% of patients (n=556).
- In patients with complete revascularization, surgical ablation was associated with a significant long-term survival benefit (HR 0.69; P=.020).
- Notably, surgical ablation on top of incomplete revascularization also demonstrated a significant long-term survival benefit (HR 0.68; P=.019) and showed similar long-term survival compared to complete revascularization without ablation (HR 0.84; P=.307).
Conclusions:
- Complete revascularization remains a critical goal in CABG surgery.
- However, for patients with atrial fibrillation and incomplete revascularization, concomitant surgical ablation provides comparable long-term survival to complete revascularization without ablation.
- This suggests surgical ablation is a viable option to improve outcomes in selected patients facing incomplete revascularization.
Background:
Surgical ablation for atrial fibrillation at the time of isolated coronary artery bypass grafting is reluctantly attempted. Meanwhile, complete revascularization is not always possible in these patients. We attempted to counterbalance the long-term benefits of surgical ablation against the risks of incomplete revascularization.
Methods:
Atrial fibrillation patients undergoing isolated coronary artery bypass grafting for multivessel disease between 2012 to 2022 and included in the HEart surgery In atrial fibrillation and Supraventricular Tachycardia registry were divided into complete revascularization, complete revascularization with additional grafts, and incomplete revascularization cohorts; these were further split into surgical ablation and non-surgical ablation subgroups.
Results:
A total of 8,405 patients (78% men; age 69.3 ± 7.9) were included; of those, 5,918 (70.4%) had complete revascularization, and 556 (6.6%) had surgical ablation performed. Number of anastomoses was 2.7 ± 1.2. The median follow-up was 5.1 [interquartile range 2.1-8.8] years. In patients in whom complete revascularization was achieved, surgical ablation was associated with long-term survival benefit: hazard ratio 0.69; 95% confidence intervals (0.50-0.94); P = .020 compared with grafting additional lesions. Similarly, in patients in whom complete revascularization was not achieved, surgical ablation was associated with a long-term survival benefit of 0.68 (0.49-0.94); P = .019. When comparing surgical ablation on top of incomplete revascularization against complete revascularization without additional grafts or surgical ablation, there was no difference between the 2: 0.84 (0.61-1.17); P = .307, which was also consistent in the propensity score-matched analysis: 0.75 (0.39-1.43); P = .379.
Conclusion:
To achieve complete revascularization is of utmost importance. However, when facing incomplete revascularization at the time of coronary artery bypass grafting in a patient with underlying atrial fibrillation, concomitant surgical ablation on top of incomplete revascularization is associated with similar long-term survival as complete revascularization without surgical ablation.
